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Page 1 SLU Sports Medicine Medical History Form Please fill out completely due to this being a part of your permanent medical record. Name: _______________________________ Pregnant: Y / N Age: ______ Date: _______________ SS#: _______________________ DOB: _______________ Right / Left Handed: _____ Date of Accident / Injury: ________ Telephone Numbers: Home ( ) ______ - _________ Cell ( ) ______ - _________ Work ( Drug Allergies: ___________________________________ ) ______ - _________ Height: ____________ Weight: ____________ Reason for Visit: ____________________________________________________________________________ Please describe the recent events of this current orthopaedic problem. Answer how long it has been a problem, what makes it worse, and what makes it better: _________________________________________________________________________________________ _________________________________________________________________________________________ Have you had/taken any of the following? (please circle all that apply) Physical therapy Other Injections (specify ________________________________) Injections of cortisone Advil, Motrin, Alleve, ibuprofen, other pain medications (specify _________) Please list all current medications: 1. 2. 3. 4. 5. 6. Past Surgeries: Please list in chronological order from oldest to newest and year of surgery. 1. 2. 3. 4. Diagnostic Studies: List any you have had for this condition along with the date and place the study was performed (MRI, CT, X-rays, EMG, etc) 1. 2. 3. 4. Family Medical History: List medical illnesses affecting your immediate family (parents, siblings) Disease Family Member Disease Family Member 1. 3. 2. 4. Page 2 Social History: Check and fill in the blanks Married ____ Single ____ Alcohol ____ Tobacco ___ Divorced ____ Live Alone ____ # of Children ____ Occasional ____ Moderate ____ Heavy ____ History of drug abuse _____ Years used ____Packs/day ____ Recreational drugs ________ Years used _____ General History: Please Check if any apply. General-Skin-Endo: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ 1 2 3 4 5 6 7 8 9 10 11 12 Weight change Fever or chills Night sweats Urinary frequency Bleeding Lumps of masses Dizziness or fainting Itching or rash Diabetes Mellitus Thyroid problems Cancer Other Gastrointestinal: ___ ___ ___ ___ ___ 1 2 3 4 5 1 2 3 4 5 Backache Joint pain Joint swelling Fractures Other ___ ___ ___ ___ ___ 1 2 3 4 5 1 2 3 4 Bleeding disorders Anemia Platelet problems Other ___ ___ ___ ___ ___ 1 2 3 4 5 Urinary tract infections Incontinence Venereal diseases Menopause Other Neurologic: Heart diagnosis / pain Hypertension Mitral valve prolapse Thrombophlebitis Other ___ ___ ___ ___ ___ 1 2 3 4 5 Ear-Nose-Throat-Eye: ___ ___ ___ ___ ___ ___ ___ 1 2 3 4 5 6 7 Hematologic Disorders: ___ ___ ___ ___ Dysphagia (swallowing difficulties) Nausea & vomiting Jaundice Hepatitis Other Cardiovascular: Musculoskeletal: ___ ___ ___ ___ ___ Genitourinary: Visual changes Hearing problems Tinnitus Dentures Bleeding gums Hoarseness Other Mental Health: ___ ___ ___ ___ 1 2 3 4 Seizures Paralysis Numbness Weakness Other Respiratory-Allergy: ___ ___ ___ ___ ___ ___ ___ ___ 1 2 3 4 5 6 7 8 Cough / sputum Rheumatic fever Tuberculosis Pleurisy / pneumonia COPD / Emphysema Asthma Shortness of breath other Depression Trouble concentrating Anxiety attacks Other Other medical conditions not listed above: 1. _______________________________________________________________________________ 2. _______________________________________________________________________________ Description of current employment / occupation: -________________________________________________ Is injury work related? ___ Yes ___ No Current litigation regarding injury: ___ Yes ___ No Which physician referred you to our office? _____________________________________________________ Name and phone number of primary care physician: ______________________________________________ ______________________________________________ Patient’s Signature ___________________ Date